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Indian Pediatr 2020;57:296-300 |
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Cognitive, Language,
and Visuomotor Abilities of Very Low Birthweight Infants at
Corrected Age of Two Years
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Kanya Mukhopadhyay, Prahbhjot Malhi, Jogender Kumar
and Pratibha Singhi
From Department of
Pediatrics, Post Graduate Institute of Medical Education and
Research, Chandigarh, India.
Correspondence to: Dr Kanya
Mukhopadhyay, Professor, Neonatology, Department of Pediatrics,
Post Graduate Institute of Medical Education and Research,
Chandigarh 160 012, India.
Email:
[email protected]
Received: January 22, 2019;
Initial review: June 08,
2019;
Accepted: November 21, 2019.
Published online:
February 5, 2020.
PII:S097475591600141
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Objective:
To assess the prevalence and
predictors of language and visuomotor delay in very low birthweight (≤1250 g) children at corrected age (CA) of
2 years.
Design: Prospective observational.
Setting: Neonatal follow-up clinic of a level
III center.
Participants: Children with
birthweight £1250 g and discharged alive (n=164) from April 2012 to
April 2013 were followed up till 2 years CA (n=126).
Methods: Development, neurological status, and
language/visuomotor cognitive skills were assessed by Cognitive
Adaptive Test/Clinical Linguistic and Auditory Milestone Scale
(CAT/CLAMS). Development Quotient (DQ) was calculated.
Main Outcome: Prevalence and predictors for the
language and visuomotor delay.
Results: At 2
years (n=123 CAT, 126 CLAMS), 30 (24%) children had below average DQ
(<90) and 93 (74%) average and above average DQ (³90) in full scale
CAT/CLAMS test. Small for gestation infants (n=86) have higher risk of
below average DQ (P=0.036). Gestational age and socioeconomic status
have a positive correlation with language development at 9 months and
2 years, respectively.
Conclusions: In VLBW
(birth weight
≥1250 g) infants, the prevalence of
language/visuomotor delay is high. Small for gestational age infants
are at higher risk for language and visuomotor development delay at 2
years corrected age.
Keywords: Clinical
Linguistic and Auditory Milestone Scale, Cognitive Adaptive Test,
Language delay, Outcome, Visuomotor delay.
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Development is a complex, multidimensional, structured process,
and aberration in it is associated with a delay and
disability in later life. It is important to perform the
developmental assessment of all children for early
identification of the delays and timely institution of
interventions to prevent adverse consequences [1]. Very low
birth weight (VLBW) infants and neonatal intensive care unit
(NICU) graduates have significant morbidities in neonatal
period, which increase their risk of developmental delays in
childhood [2,3]. The develop-mental delay may involve either
all the five domains of development (language, gross motor,
visuomotor, adaptive and social) or a particular domain.
Multiple screening as well as diagnostic tools exist to
identify the delay/dissociation in the development process
[4,5].
The Bayley Scales of Infant Development (BSID)
is a frequently used scale to evaluate the neurodevelopment
in children; however, it requires expertise, training and is
time-consuming which makes it difficult to use in general
practice [4,6]. The Cognitive Adaptive Test/Clinical
Linguistic and Auditory Milestone Scale (CAT/CLAMS) was
designed for cognitive, language and visuomotor development
assessment by pediatricians in general practice. It takes
10-20 minutes and has good correlation with BSID in normal
as well as high-risk children [7,8].
We aimed to
evaluate the prevalence and predictors for delayed language
and visuomotor development in babies with birthweight
≤1250 g at a corrected age of two years
using CAT/CLAMS tool.
Methods
This prospective cohort study was conducted in the
neonatal follow-up clinic of a tertiary center from April
2012 to April 2015. All babies born from April 16, 2012 to
April 15, 2013, with a birthweight of
≤1250 grams were enrolled after taking
written informed consent from the parents and followed up
till 2 years corrected age (CA) for language and visuomotor
assessment. The study was approved by the institute research
ethics committee.
All cases were followed at neonatal
follow-up clinic at CA of 40 weeks, 3 months, 6 months, 9
months, 12 months, 18 months, and 2 years. During these
visits, anthropometry, neurological examination [9] and
development assessment [6] were done by a neonatologist.
Brainstem evoked response audiometry (BERA) was performed in
all children at CA of 3 months. At 9 months and 2 years CA,
their language and visuomotor development skills were
assessed by the Capute scale - Cognitive Adaptive
Test/Clinical Linguistic and Auditory Milestone Scale
(CAT/CLAMS) by a trained clinical psychologist. The
developmental quotient (DQ) scores were calculated in each
domain by dividing the age equivalent score for the given
scale by the chronological age and multiplying by 100 to
express as a percentage. Full-scale CAT/CLAMS DQ (FS DQ) was
calculated by averaging the CAT and CLAMS development
quotients. The CAT/CLAMS/FSDQ was further categorized as
follows: <70, delayed; 70-79, borderline; 80-89, below
average; 90-109, average and
≥110, above average. To simplify the
analysis, these categories were further divided into below
average if DQ<90, and average and above if DQ
≥ 90.
The Capute Scale (CAT /CLAMS)
is a development assessment tool to quantitatively measure
receptive and expressive language skills along with
nonverbal problem-solving skills in infants from 0 to 36
months of age [8,10]. CLAMS is for language assessment and
it relies mostly on parental history in the first 18 months
of life and thereafter on a combination of parental history
and observation skills of the examiner, whereas CAT deals
with visuomotor problem-solving skills and requires direct
observation of a child performing a specific task during the
assessment. In contrast to other commonly used screening
tools which give pass/fail results, this is a quantitative
assessment tool that determines the degree as well as the
type of the developmental delay. This tool has got
importance due to its objective nature and quick
administration even by trainee residents/fellows.
The
primary outcome measure was to estimate the prevalence of
cognitive and language delay and secondary outcome measure
was to identify the risk factors for the delay in VLBW
(birthweight
≤ 1250 g) children at 2 years corrected
age.
Statistical analyses: The basic demographics
were expressed as percentages for categorical variables,
mean (SD) for normally distributed continuous variables on
the Shapiro-Wilk test and as median (1st, 3rd quartile) for
skewed distributed continuous variables. Categorical
variables were compared between groups by chi-square test or
Fisher exact test as applicable. The Pearson correlation
coefficient (including Biserial correlation, if applicable)
was used to assess correlation among groups with normally
distributed continuous variables. SPSS version 20 software
was used for analysis.
Results
A total of 341 babies with birth weight £ 1250 g were
enrolled of whom 202 were admitted in NICU – 164 (48%) were
discharged alive, 11 (3.2%) died in NICU and 27 (8%) left
against medical advice. The remaining 139 (41%) had died in
delivery room either due to resuscitation failure at birth,
non-receipt of optimal care due to inadequate
infrastructure, extreme prematurity or other reasons. Of the
164 discharged infants, 126 (85%) were assessed at 2 years,
16 infants had died (10%) and 22 were lost to follow up
(13%). The demographic details and baseline character-istics
of the discharged infants are shown in Table I.
The outcome at 9 months and 2 years corrected age
respectively, are shown in Table II.
Table III presents the predictors for
abnormal language development at 2 years. Small for
gestational age status is associated with below average
(DQ<90) language and visuomotor development [OR (95% CI) ,
2.5 (1.1-5.8); P=0.036] . DQ’s correlation with other
variables was also performed. Gestational age had a weak but
significant (P =0.01) positive correlation with CLAMS (r =
0.38) and full-scale DQ (r = 0.33) at 9 months; however, it
was not significant at 2 years. A weak, but a significant
positive correlation (using Biserial correlation) was also
observed between higher socioeconomic status (score > 15 on
Kuppuswamy scale) and CLAMS and full scale DQ score at 2
years (r = 0.21 and 0.21, respectively, P<0.01).
Importantly, CAT score and CLAMS score at 2 years have
moderate but significant positive correlation (r = 0.53,
P<0.01) with each other suggesting the development of one
domain is closely related to another. CAT score at 9 months
had weak, but the significant (P<0.01) positive correlation
with CAT DQ (r = 0.28) and full-scale CAT/CLAMS DQ (r =
0.28) score at 2 years. Language and visuomotor skill
development (full scale DQ) at 9 months had a strong
positive correlation with full scale CAT/CLAMS DQ at 2 years
(P<0.01). Overall, 9 months assessment correlates well with
language/visuomotor development at 2 years.
Table I Baseline Demographic Characteristics of the Very Low Birthweight Infants (N=164)
| Characteristics | Value | | *Gestation (wk) | 30.7 (2.8) | | *Birthweight (g) | 1051 (147) | | #Male | 74 (39.8) | | #Appropriate for gestational age | 78 (47.6) | | #Small for gestational age | 86 (52.4) | | #Rural residence | 74 (45.1) | | #Maternal education (n=120) | | Illiterate | 4 (3.3) | | Primary school certificate | 7 (5.8) | | Middle school certificate | 19 (15.8) | | High school certificate | 33 (27.5) | | Intermediate | 14 (11.7) | | Graduate/Postgraduate | 39 (32.5) | | Professional/Honors | 4 (3.3) | | ‡#Socioeconomic status (Kuppuswamy scale) | | Upper | 30 (18.3) | | Upper middle | 42 (25.6) | | Lower middle | 54 (32.9) | | Upper lower | 30 (18.3) | | Lower | 8 (4.9) | | #Absent/Reduced end diastolic flow on doppler | 37 (22.6) | | #Intraventricular hemorrhage | 49 (29.9) | | Grade I/II | 43 (26.2) | | Grade III/IV | 6 (3.7) | | Values are expressed as *Mean (SD) or #n (%), PCA: Post conceptional age; ‡antenatal doppler. |
Table II Language and Visuomotor Development at 9 Month and 2 Years Corrected Age
| Outcome parameter | 9 mo (n=83) | 2 years | | Cognitive adaptive test * | | (n=123) | | #Composite Score | 101 (9) | 95.3 (10.7) | | Delay (<70) | 1 (1.2) | 5 (4.1) | | Borderline (70-79) | 2 (2.4) | 3 (2.4) | | Low average (80-89) | 3 (3.6) | 21 (17.1) | | Average (90-109) | 59 (71.1) | 84 (68.3) | | Above average (110 or more) | 18 (21.7) | 10 (8.1) | | Clinical linguistic and auditory milestone scale | (n=126) | | | #Composite score | 98.5(11.1) | 94.9 (15.7) | | Delay (<70) | 2 (2.4) | 9 (7.1) | | Borderline (70-79) | 3 (3.6) | 9 (7.1) | | Low average (80-89) | 9 (10.8) | 21 (16.7) | | Average (90-109) | 50 (60.2) | 68 (54.0) | | Above average (110 or more) | 19 (22.9) | 19 (15.1) | | Full scale developmental quotient | | (n=123) | | #Composite score | 99.7(9) | 95.0 (11.6) | | Delay (<70) | 1 (1.2) | 5 (4.1) | | Borderline (70-79) | 2 (2.4) | 6 (4.9) | | Low average (80-89) | 7 (8.4) | 19(15.4) | | Average (90-109) | 62 (74.7) | 85 (69.1) | | Above average (110 or more) | 11 (13.3) | 8 (6.5) | | *3 children were not cooperative for cognitive adaptive test; Figures expressed as n (%); #expressed as Mean (SD). |
Table III Predictors of Language and Visuomotor Development at the Corrected Age of Two Year
| Parameter | Category | #CAT DQ | P | CLAMS DQ | P | FS DQ | P | | Below | Average | | Below | Average | | Below | Average | | | Average | and above | | Average | and above | | Average | and above | | | (n=29) | (n=94) | | (n=39) | (n=84) | | (n=30) | (n=93) | | | Gestation (wk) | <28 | 8 (24.2) | 25 (75.8) | 0.9 | 12 (27.3) | 22 (72.7) | 0.5 | 11 (33.3) | 22 (66.7) | 0.1 | | Birthweight (g) | < 1000 | 9 (21.4) | 33 (78.6) | 0.8 | 10 (23.2) | 33 (66.8) | 0.2 | 9 (21.4) | 33 (78.6) | 0.6 | | Sex | Female | 15 (24.2) | 47 (75.8) | 1.0 | 23 (35.4) | 42 (64.6) | 0.3 | 16 (25.8) | 46 (74.2) | 0.8 | | Maternal education | Less than graduate | 19 (27.1) | 51 (72.9) | 0.2 | 27 (28.1) | 44 (71.9) | 0.055 | 20 (28.6) | 50 (71.4) | 0.2 | | Father's education | Less than graduate | 20 (26.0) | 57 (74.0) | 0.5 | 28 (35.4) | 51 (64.6) | 0.1 | 20 (26.0) | 57 (74.0) | 0.6 | | Residence | Rural | 13 (25.5) | 38 (74.5) | 0.8 | 19 (35.9) | 34 (64.1) | 0.3 | 12 (23.5) | 39 (76.5) | 1.0 | | *SES | Lower | 22 (23.2) | 73 (76.8) | 0.8 | 29 (29.6) | 69 (70.4) | 0.5 | 23 (24.2) | 72 (75.8) | 1.01 | | SGA | Yes | 13 (24.5) | 40 (75.5) | 0.8 | 19 (35.2) | 35 (64.5) | 0.3 | 18 (34.0) | 35 (66.0) | 0.04 | | IVH | Yes | 11 (30.6) | 25 (69.4) | 0.2 | 12 (32.4) | 25 (67.6) | 0.8 | 12 (33.3) | 24 (66.7) | 0.1 | | BERA | Abnormal | 4 (50.0) | 4 (50.0) | 0.08 | 4 (50.0) | 4 (50.0) | 0.2 | 2 (25.0) | 6 (75.0) | 1.0 | | CAT: Cognitive Adaptive Test; CLAMS: Clinical Linguistic and Auditory Milestone Scale; FS: Full scale CAT/CLAMS; DQ: Development quotient; IVH: Intraventricular hemorrhage; SGA: Small for gestational age; BERA: Brainstem evoked response audiometry; SES: Socioeconomic status; #CAT could not be performed in 3 cases; P<0.05 considered significant; *Modified Kuppuswamy's socioeconomic status scale; lower (score <15); Below average (DQ<90) and average and above (DQ≤90) for all scales. |
Discussion
In the present study
about one-fourth of the children had below average language
and visuomotor development skills (composite DQ <90). SGA
status was strongly associated with below average visuomotor
and language develop-ment at 2 years. Higher gestational age
and higher socioeconomic status positively correlate with
better language development. Similarly, language and/or
visuomotor development at 9 months had a significant
positive correlation with the language and visuomotor skills
at 2 years corrected age.
The observations on
Language delay are in concordance with the previous studies
[11-13]. A recent cross-sectional study from Indonesia among
toddlers in community settings using CAT/CLAMS full-scale DQ
scores found that 16 % babies had suspect/delay in cognitive
development [14]. The higher prevalence noted in the present
study is likely due to differences in the study population.
Previous studies have shown conflicting results on
association of language develop-ment and gender [11, 15,16].
However, no gender difference in language development was
noted in the present study.
We found a significant
correlation between socioeconomic status and language
development, consistent with previous studies [17-19]. Just
as in previous studies, the present study also noted that
SGA babies had poor composite language and visuomotor
outcome as compared to the appropriate for gestational age
(AGA) babies [20,21]. This may be related to an insult to
the neural architecture in the frontal lobe leading to the
volume reduction of the frontal lobe.
The
limitations of our study are that we had a low follow up
rate at 9 months, hence, could not compare the outcomes
between 9 and 24 months. Also, we assessed by using only one
measure of language development and not by formal speech
assessment scale. Multiple measures may have provided more
accurate results. The strength of our study is its
prospective nature, large sample size, detailed structured
assessment with a validated tool, hearing assessment (BERA)
for all subjects and good follow up (85%) till 2 years.
In conclusion, a quarter of VLBW (birth weight
≥1250 grams) children had below average DQ
for language and visuomotor development. Higher gestation
and socioeconomic status have a positive correlation with
language development. We recommend that the structured
language assessment, as well as speech stimulation, should
be a part of the routine follow up in high-risk clinics.
Acknowledgements: Mrs Smita Gupta (Psychologist), Mrs
Sonia Sharma (Social worker), Mrs Parul (Physiotherapist),
Mr Kanwar Mohan (Audiologist), Dr Naresh Panda (ENT), and Dr
MR Dogra (Ophthalmology) for their help in the recruitment
of children, ensuring timely follow up, psychological
evaluation, and hearing assessment.
Contributors: KM:
conceptualized and designed the study, collected data, and
critically revised the manuscript; PM: substantial
contribution to the concept and design of the study;
supervised the cognitive, language, and visuomotor
development assessment and critically revised the
manuscript; JK: substantial role in acquisition, analysis,
and interpretation of data; and drafted the manuscript; PS:
substantial contribution to the concept and design of the
study; supervised neurological and developmental assessments
and critically revised the manuscript. All the authors
approved the final version of the manuscript and will be
accountable for all aspects of the work in ensuring that
questions related to the accuracy or integrity of any part
of the work are appropriately investigated and resolved.
Funding: ICMR New Delhi. IRIS ID:
2010-04980/384 dated 5/7/2010; Competing interest: None
stated.
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What is Already Known?
• Language and visuomotor delay is a common
problem in very low birth weight infants.
•
There are several social, environmental, and
biological risk factors for language and visuomotor
delay.
What This Study Adds?
• One-fourth of VLBW (birthweight
≤1250 g) infants have composite language
and visuomotor delay.
• Small for gestational
age infants are at higher risk of language and
visuomotor delay. |
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